The future of general practice: Personal care or the polyclinic?

BMJ 1991;302:1514-6 One set of responses to three key subjects discussed in Building Your Own Future would produce a change from traditional British general practice, based on personal care, towards a system of general practices as polyclinics. At present general practitioners contract to provide services as individuals, their numbers are still intended to expand to achieve average list sizes of 1700, and their role is only gradually expanding into health promotion and into prevention. The strategy document speculates that family health services authorities may in future contract with practices instead of individuals (and that many general practitioners may therefore be salaried); that the role of the general practitioner in prevention, management of chronic disease, and care of patients discharged early from hospital may continue to grow; and that the number of principals may fall, with the possible emergence of a hierarchy among general practitioners. Let us suppose that the profession chooses to endorse policies that encourage further extension of general medical services and the role of the general practitioner, further growth in the size of practices and practice teams, but a reduction in the overall number of principals and an increase in average list sizes. Although the strategy document makes little mention of the contentious issue of fundholding, such larger practices would clearly be likely to hold funds if this option survives. We may imagine what such a practice might be like and then consider what would be gained and what lost should such practices dominate the provision of primary health care services. Firstly, however, it is worth considering in more detail the debate about list sizes.